Against the Grain: D. J. Jaffe’s 8 Myths About Mental Illness

D. J. Jaffe’s name has been popping up in news articles lately, most often defending Rep. Tim Murphy’s mental health legislation. I noticed a quote from him earlier this week in a special report entitled THE COST OF NOT CARING: NO WHERE TO GO — The financial and human toll for neglecting the mentally illpublished by USA Today medical writer, Liz Szabo, a reader of this blog. D.J. is a familiar figure having been involved in the National Alliance on Mental Illness and the Treatment Advocacy Center before starting his own non-profit advocacy group called Mental Illness Policy Org.

I bumped into him on Capitol Hill recently and suggested he write a guest blog for me, which he has kindly done. (I also extended invitations to advocates who share a different point of view than his but they have yet to respond.)

8 MYTHS ABOUT SERIOUS MENTAL ILLNESS by D.J. Jaffe

These myths about serious mental illness in the United States are believed by many mental health advocates and cause Congress to waste money and fail to implement policies that can improve care and keep patients, the public and the police safer.

1. All mental illness is serious.

100% of adults can have their mental health improved. Twenty percent of adults over 18 have a diagnosable mental illness. But serious mental illnesses are rare. Only 4% have a serious mental illness including the 1.1% of adults with schizophrenia and the 2.2% with severe bipolar disorder. Until the early 1960s virtually all mental health expenditures were spent on seriously ill people in state psychiatric hospitals, but federal and state dollars are now spent improving the mental health of all citizens including people without mental illness.

2. Violence is not associated with mental illness.

Studies that show no association between mental illness and violence are flawed. These studies are almost always of adults with mental illness who are treated.They show that medications work, not that mental illness and violence aren’t connected. Studies also dilute their results by studying the 20% of adults with any mental illness instead of the 4% with serious mental illness. Because the studies are typically done in the uninstitutionalized community, they exclude the violent who are involuntarily committed, incarcerated, hospitalized, or who have killed themselves. Numerous studies show that people with untreated serious mental illness are as a group more prone to violence than others. A meta-analysis of 204 studies of psychosis found it “was significantly associated with a 49%–68% increase in the odds of violence.” A review of 22 studies published between 1990 and 2004 concluded “major mental disorders, per se, especially schizophrenia, even without alcohol or drug abuse, are indeed associated with higher risks for interpersonal violence.” Researcher John Monahan found, “The data that have recently become available, fairly read, suggest the one conclusion I did not want to reach…no matter how many social or demographic factors are statistically taken into account, there appears to be a relationship between mental disorder and violent behavior.”

3. Stigma is a major impediment to receiving care.

A 2011, Substance Abuse and Mental Health Services Administration (SAMHSA) report shows, as do most other studies, that stigma is low on the list of why people with mental illness do not receive care. The SAMHSA report demonstrated that cost, was a far more significant impediment to treatment than stigma. Allocating the millions of dollars spent on reducing stigma to subsidizing the cost of care would be a more effective use of funds. Other studies show anosognosia, lack of insight or awareness of illness is the major impediment to receiving care. It affects up to 40% of those with schizophrenia and bipolar. Because the illness prevents these individuals from understanding they are ill they are ill, they refuse to seek or accept treatment.

4. Psychiatric hospitals should be replaced by community services.

Psychiatric hospitals and community services serve two mutually exclusive populations. Hospitals serve those who currently need hospitalization, while community services serve those who don’t. Even with perfect community services in place, some people will need to be hospitalized. The minimum number of beds needed to serve the most seriously mentally ill is 147,000, roughly 50 beds per 100,000citizens. We are therefore short 95,000 beds. Because of this shortage, 360,000 individuals with mental illness are behind bars and 200,000 are homeless. Until there are better treatments, we need hospitals.

Today, community services are not a substitute for hospitals, mainly because they only accept those well enough to recognize their need for treatment. People who are not well-enough to self-direct their own care, or are highly symptomatic, or have a criminal history, generally will not be welcomed by community-based programs. And even if they gain access,community services do not offer the evidence-based treatment that’s needed to improve meaningful outcomes for the most seriously ill. Peer-support–whereby someone with mental illness is placed under the guidance of someone else who’s only qualification they too have a mental illness—is currently a popular community based service. But it has not been proven to reduce homelessness, suicide, arrest or incarceration of the seriously ill. Likewise, 90% of the most seriously ill, will not recover enough to become competitively employed so job training and back-to-school programs are of little utility.

Police Chief Michael Biasotti, Immediate Past President of the New York State Association of Chiefs of Police correctly told Congress, “We have two mental health systems today, serving two mutually exclusive populations: Community programs serve those who seek and accept treatment. Those who refuse, or are too sick to seek treatment voluntarily, become a law enforcement responsibility. …(M)ental health officials seem unwilling to recognize or take responsibility for this second more symptomatic group.”

5. Treatments that are involuntary are by definition bad.

Not everyone can accept voluntary treatment. Some people will always have hallucinations, delusions and/or anosognosia. For them, lack of voluntary treatment means no treatment. John Hinckley ‘knew’ the best way to get a date with Jodie Foster was to shoot Ronald Reagan. Some seriously ill people need involuntary interventions to prevent the worst from happening. Assisted Outpatient Treatment (AOT) is an involuntary intervention that is very humane and less restrictive than anything else now being offered. AOT is limited to the small group of those with serious mental illness who have already accumulated multiple prior arrests, incarcerations or hospitalizations caused by going off treatment. In those limited cases- after full due process- a judge can order the ill individual to stay in mandated and monitored treatment as a condition for living in the community and order he mental health system to provide the necessary treatment.

AOT has been proven to reduce arrest, suicide, hospitalization and violence over 70% each. By replacing more expensive and liberty-depriving inpatient commitment and incarceration with less expensive outpatient treatment, AOT cut taxpayers’ costs in half. One parent described AOT as putting a fence by the edge of the cliff, rather than an ambulance at the bottom. Eighty-one percent of those enrolled in AOT retrospectively said it helped them “get well and stay well.” As civil libertarian Herschel Hardin wrote, “The opposition to involuntary committal and treatment betrays a profound misunderstanding of the principle of civil liberties. Medication can free victims from their illness – free them from the Bastille of their psychoses – and restore their dignity, their free will and the meaningful exercise of their liberties.”

6. People with mental illness are more likely to be victims than perpetrators.

Perpetration studies usually exclude persons with mental illness who abuse substances and therefore artificially lower rates of perpetration. Conversely, the victimization studies used for comparison include people with who abuse substances which raises victimization rates. The first study of equivalent populations found people with bipolar disorder and major depression are more likely to cause injury than receive it.[1] However, the ratio of perpetration to victimization is largely irrelevant. Treatment can reduce both.

7. Serious mental illness can be predicted and prevented.

The causes of serious mental illnesses like schizophrenia, bipolar disorder and severe major depression remain unknown and therefore we can’t prevent them. No one can predict who will develop mental illness until the symptoms become manifest. Poverty, lower education and broken families may be associated with serious mental illness but are not known to be causal. Genetics play a role, but it is not well understood. The Substance Abuse and Mental Health Services Administration (SAMHSA) and California’s Mental Health Services Act Oversight and Accountability Commission (MHSOAC) allocate millions to mental health programs that claim they can predict or prevent serious mental illness.

8. Everyone Recovers.

Some people do not. To improve care for adults with the most serious mental illnesses, we have to fund science, not mythology. The “Helping Families in Mental Health Crisis Act“ (HR3717) introduced by Rep. Tim Murphy along with 73 co-sponsors in both parties does that.

[1]Sarah L. Desmarais, Richard A. Van Dorn, Kiersten L. Johnson, Kevin J. Grimm, Kevin S. Douglas, and Marvin S. Swartz. (2014). Community Violence Perpetration and Victimization Among Adults With Mental Illnesses.American Journal of Public Health. Like many studies of violence among persons with mental illness, this one excluded persons with mental illness in jails, prisons and those who were involuntarily committed. This artificially lowered violence rates by excluding those most likely to be violent. The significant finding that people with mental illness were more likely to perpetrate violence than be victimized by it was in the report, but not the abstract. The authors created two descriptions of “violence”. One definition (“community violence”) did not require having received or given an injury. The other definition (“violence”) did. The abstract focused on community violence–violence without injury–and reported that people with mental illness are more likely to be victims than perpetrators. But when injury occurred the results were different. More were perpetrators of injury-causing violence (8.7%) than victims of injury causing violence (7.5%). Results like that should be highlighted, not buried.